A few years ago, I saw four patients within two weeks that caused a profound change in my thinking about patients’ perception of pain.
I historically would focus on pain patterns and correlate them with imaging studies. If the symptoms seemed to be caused by the anatomical abnormality, I would consider surgery. If there was not a match, surgery wasn’t an option. I have long considered anxiety as a factor that affected the level of pain, but not as a primary complaint. I have since learned that anxiety is what signals “danger” and is the pain.
The conversation with these four men was around the decision to undergo spine surgery. All were successful professionals between the ages of 45 and 65. They had leg pain originating from an identifiable problem in their spine, and it was severe enough that each wanted to have surgery. I noticed on the intake questionnaire that they were all at least an 8 out of 10 on the anxiety scale and weren’t sleeping well. Their stresses included seriously ill children, loss of jobs, marital problems, other medical problems, and none of them were coping that well.
Can you live with your anxiety?
They were familiar with the self-directed care program for solving chronic pain, Direct your Own Care (DOC). The principles and tools are presented on the website, www.backincontrol.com. They were skeptical and had not engaged with the concepts at a meaningful level. They were coming back for their second and third visits.
Finally, I asked each of them the same question, “What would it be like if I could surgically solve the pain in your leg, but the anxiety you are experiencing would continue to progress?” Their eyes widened with a panicked look and they replied, “That would not be OK. I couldn’t live like this.” Each of them also grabbed his leg and asked, “Won’t getting rid of this pain alleviate my anxiety?” My answer was “No.”
Anxiety is a reaction to any threat. Although surgically removing the spur and decreasing the pain would relieve some anxiety, it wouldn’t come close to solving it. Your brain will land on something else to worry about. Solving anxiety is a different problem requiring a specific skill set.
I told them that although I would love to get rid of their leg pain with surgery, my bigger concern was their severe anxiety and possibly chronic pain. I recalled my 15-year battle with pain and anxiety. I was on an endless quest to find the one answer that would give me relief; especially for the anxiety. I also remembered the intensity of that need. At that moment I realized that each of these patients felt that by getting rid of the pain they could lessen or solve their anxiety.
It is actually the opposite scenario. As your anxiety resolves, it is common for pain to abate. As stress chemicals decrease, nerve conduction slows and there is less pain. The techniques for addressing anxiety don’t include surgery. Also, after a failed surgery, another level of hope has been taken away.
Can you live with your leg pain?
Then I asked each of them that if I could help them resolve their anxiety but they would have to live with their leg pain, what would that be like? Although not completely happy about the scenario they thought they could deal with it. It was more palatable than experiencing no improvement in their fear.
“No” to surgery
These patients didn’t want to jump to surgery, and they wanted to give the DOC program a try. Within six to twelve weeks as they calmed their nervous system, their pain disappeared or subsided to the level where they weren’t even considering surgery. Although I know pain and anxiety are linked circuits, I had never realized that for many patients the pain relief they were asking for was really for peace of mind.
Conversely, I’ve had many patients over the years undergo a successful surgery for a severe structural problem with no improvement or worsening of their pain. Now I understand. “Neurons that fire together wire together.” Pain, anxiety, and anger are tightly intertwined. As long as the anxiety/anger pathways are fired up, they will keep the pain circuits firing.
Deciding on Surgery
My surgical decision-making dramatically changed over the last five years of my practice. In spite of watching so many successes of people healing from chronic pain without surgery, I still had a surgical mindset and was always looking for a surgical lesion that I could “fix”.
In the first edition of my book, Back in Control: A Surgeon's Roadmap Out of Chronic Pain, my advice was that if you had a surgical problem, get the surgery done first and engage in the rehab process later. But I wasn’t aware of the research that shows there is a 40% chance of inducing chronic pain as a complication of any surgery if you operate in the presence of untreated chronic pain in any part of the body. It can become a permanent problem 5-10% of the time. (1)
Chronic pain as a complication of surgery is not a well-known concept. If I had a neurological complication rate of 5%, I would not have remained in practice for long. This occurs even if the procedure goes well.
I can’t put into words the depth of the paradigm shift that occurred with these four patients. As much as I knew about anxiety, I did not remotely place pain complaints and anxiety in the same bucket. My surgical decision-making changed dramatically and we instituted a program of rehab before elective surgery in every patient for at least 8-12 weeks.
Many patients with surgical problems canceled surgery because the pain (anxiety) resolved, including these four men. Surgery may or may not help your arm or leg pain. It rarely solves neck or back pain. It really doesn’t work for anxiety. What relief are you asking your surgeon for?
1. Ballantyne J, et. al . Chronic Pain after Surgery or Injury. IASP (2011); 1-5.